Title: Director/Senior Director of ComplianceFLSA Category: ExemptReports To: Chief Executive OfficerDate Issued: May 2026Job SummaryThe Director/Senior Director of Compliance will build, lead, and oversee a comprehensive organizational compliance program from the ground up at Greater Baden Medical Services (GBMS). Reporting directly to the Chief Executive Officer (CEO), this individual serves as a hands-on subject-matter expert and program owner. The Compliance Director is responsible for the day-to-day management and execution of the organization's compliance, privacy, and regulatory support activities.
The ideal candidate is an agile, forward-thinking leader who thrives in a dynamic environment. They must possess a deep passion for continuous learning and have a proven ability to adapt to an evolving organizational structure while embedding a culture of compliance, integrity, and accountability across all service lines.
Essential Duties & ResponsibilitiesCompliance Program Leadership & Adaptability- Program Architecture: Design, implement, and lead GBMS's formal corporate compliance program in strict alignment with HRSA, CMS, OIG, FTCA, and HIPAA requirements.
- Evolving Structure Management: Establish a strategic roadmap for building program components over time. Partner closely with executive leadership to adapt compliance frameworks as the organization's structure grows and evolves.
- Culture of Integrity: Foster organizational awareness, reinforcing ethical conduct, accountability, and transparency through ongoing consultation and education.
Regulatory Readiness & FQHC Oversight- HRSA & OSV Readiness: Serve as the primary operational contact and project manager for HRSA Operational Site Visits (OSVs) and other federal reviews. Maintain continuous audit readiness via internal checklists, mock reviews, and structured document management.
- FTCA Claims & Risk Management: Lead the management, tracking, and processing of HRSA Federal Tort Claims Act (FTCA) activities. Serve as the main point of contact for claims administrators and legal counsel.
- Accreditation & Quality Standards: Drive compliance preparation and documentation tracking to maintain the organization's Joint Commission accreditation and alignment with clinical quality metrics.
- Specialized Program Monitoring: Oversee regulatory adherence for targeted FQHC service line programs, including the 340B Pharmacy program landscape, sliding fee discount programs, and data integrity for UDS reporting.
Payer, Licensure, & Multi-Level Government Compliance- Medicare & Medicaid Management: Oversee regulations, provider enrollment, and billing rules associated with Medicare and Medicaid/Managed Care programs, ensuring strict adherence to federal and state healthcare laws.
- Licensure & Certification: Partner with clinical and operational teams to ensure all site licenses, clinic certifications, and professional credentialing/privileging processes are kept up to date.
- State & Local Guardrails: Actively monitor, interpret, and translate complex federal, state, and regional/local healthcare requirements into clear operational policies and clinical guidance.
Auditing, Investigations, & Incident Response- Internal Audit Workplan: Prepare and execute an annual risk assessment and compliance workplan, targeting high-risk areas such as clinical documentation, coding, and billing compliance.
- Grievances & Internal Reporting: Administer internal compliance systems used for the intake, tracking, and confidential reporting of compliance concerns, patient incidents, and grievances.
- Investigations & Remediation: Conduct thorough root-cause analyses and investigations regarding noncompliance or privacy breaches. Develop, implement, and track corrective action and remediation plans to completion.
Privacy, Security, & Board Reporting- HIPAA Privacy & Security Officer: Serve as the designated HIPAA Privacy/Security Officer. Manage policies, workforce training, and the execution/monitoring of Business Associate Agreements (BAAs).
- Governance Communication: Prepare and present quarterly compliance reports, risk assessments, and tracking dashboards directly to the CEO, Board of Directors, and Board Compliance Committees.
Requirements and QualificationsEducation & Credentials- Juris Doctor (JD) degree preferred from an accredited law school.
- Bachelor's or Master's degree in Healthcare Administration, Public Health, Business, or a closely related field required.
- Certified in Healthcare Compliance (CHC) or Certified in Healthcare Privacy Compliance (CHPC) highly desirable.
Experience & Knowledge- FQHC Experience Required: Minimum of 5-8 years of direct healthcare compliance, privacy, or regulatory leadership experience specifically within a Federally Qualified Health Center (FQHC) environment.
- Federal Program Mastery: Proven, deep working knowledge of the HRSA Health Center Program requirements, FTCA compliance obligations, and Joint Commission accreditation standards.
- Multilevel Regulatory Literacy: Extensive familiarity with federal healthcare legislation (including HIPAA/HITECH), Medicare/Medicaid regulations, and navigating state and local regulatory frameworks.
- Audit & Investigation Track Record: Demonstrated success designing internal audit workflows, conducting healthcare risk assessments, managing external federal audits, and leading compliance investigations.
Work EnvironmentStandard office environment with routine use of computers, phones, and office equipment.
Physical and Mental DemandsIncludes sedentary work, frequent computer use, multitasking, frequent communication, ability to manage interruptions, adjust priorities, and perform basic physical office tasks including light lifting (up to 25lbs).
Language SkillsAbility to read, interpret, and communicate written and verbal instructions effectively with employees, candidates, and stakeholders.
ComplianceMust comply with Greater Baden Medical Services policies, compliance standards, and Code of Conduct.
TravelMust be able to travel between GBMS locations as needed.
